The Ohio Department of Health (ODH) announced that the Centers for Disease Control and Prevention (CDC) issued a report examining the increase in unintentional fentanyl-related drug overdose deaths in Ohio. ODH requested CDC’s assistance in September 2015 after 2014 drug overdose data showed that Ohio’s fentanyl-related overdose deaths increased from 84 in 2013 to 502 in 2014, a 500 percent increase. Preliminary data also indicated that the number of fentanyl-related deaths in Ohio was continuing to increase in 2015.

Fentanyl-related deaths in Ohio also accounted for 20 percent of all drug poisoning deaths in 2014, a substantial increase over the 4 percent in 2013. According to a CDC Health Alert Network advisory, Ohio also ranked number one in the nation in total fentanyl seizures in 2014, with 1245 compared to the second ranked state, Massachusetts, which had a total of 630 seizures.

Ohio’s Public Health Response

The ODH has launched a comprehensive response to the increase in fentanyl-related deaths. A broad overview of these activities can be found on the Ohio Mental Health and Addiction services website. They include: (1) investment of $1 million over the fiscal years 2016-2017 to expand access to naloxone (a medication used to block the effects of opioids, especially in overdose) through local health departments; (2) growth of the governor’s Start Talking! initiative to continue efforts to prevent drug use before it starts; (3) increased functionality of prescription drug monitoring through improvements in the usability of Ohio’s Automated Rx Reporting System (OARRS); and (4) continued work with communities to enhance local efforts through the Health Resources Toolkit for Addressing Opioid Abuse.

CDC Assistance Sought

As part of its public health response, the ODH also requested CDC’s assistance in an epidemiologic investigation (EpiAid) to examine the ongoing increase in unintentional fentanyl-related overdose deaths in their state. To that end, on October 26, 2015, CDC’s Epidemic Intelligence Service (EIS) Officers deployed to Columbus, Ohio, and in conjunction with ODH officials, conducted a three-week investigation which included visits to four regional hotspots of the epidemic (Hamilton, Cuyahoga, Scioto, and Montgomery Counties).

CDC Findings

The CDC discovered that the sharp increase in fentanyl-related deaths in Ohio appeared to closely coincide with a similar sharp increase in the confiscation of illicitly-produced fentanyl by law enforcement in Ohio, based on data obtained from the U.S. Drug Enforcement Administration (DEA). On March 18, 2015, the DEA issued a nationwide alert on fentanyl as threat to health and public safety.

The CDC found that the majority of the Ohio population experiencing fentanyl-related unintentional overdose deaths were male (69 percent), white (89 percent), never married (55 percent), and had some college or less education (94 percent). The average age of fentanyl decedents was 37.9 years old, with ages ranging from 17 to 71 years old. Although large metropolitan counties (population more than 1 million) had a higher number and percentage of all fentanyl-related deaths (47 percent), moderate metropolitan counties (population 250k to 1 million) had the highest rate of fentanyl-related deaths (6.63 per 100,000).

The report showed that the risk factors for fentanyl-related overdose deaths in Ohio included: male gender, white race, some college or less education, history of substance abuse problem, and current mental health problem (e.g., depression, anxiety, or bipolar disorder). Additional risk factors included a recent release from an institution within the last month (e.g. jail, hospital, and treatment facility), and a history of using high-dose opioid prescriptions.

The report also showed a correlation between heroin and fentanyl deaths in Ohio. For example, approximately 62 percent of all fentanyl and heroin decedents had a record of at least one opioid prescription from a healthcare provider during the seven years preceding their death. In addition, one in 10 heroin decedents, and one in 5 fentanyl decedents, had an opioid medication prescribed to them at the time of their death.

Further analysis of OARRS data revealed that substantial percentages of fentanyl and heroin decedents (40 percent and 33 percent, respectively) had been prescribed an opioid at high doses (at least 90 morphine milligram equivalents) at some point in the seven years preceding death. The CDC suggested further analysis to determine the duration and timing of these high dose opioid prescriptions.

CDC Recommendations

CDC’s recommendations to OPH focused on enhancing public health surveillance for fentanyl morbidity and mortality, targeting of public health response to high-burden counties and high-risk groups, enhancing and facilitating response to fentanyl-related overdoses by emergency personnel and laypersons, and improving access to naloxone and addiction services.

A statute in Ohio which prohibits Medicaid providers or persons with an ownership interest in a Medicaid provider from making campaign contributions to candidates for state Attorney-General or county-prosecutor is unconstitutional (Lavin v Husted, August 3, 2012, Kethledge). The ban on contributions restricts fundamental First Amendment interests and is more restrictive than necessary to achieve its goal of preventing corruption.

First Amendment interests. Limitations on campaign contributions involve the fundamental freedoms of political association and expression and are only acceptable if the state can show they are “closely drawn” to a sufficiently important interest. While the state claimed its interest was the prevention of corruption, it could not demonstrate evidence that prosecutors abused their discretion by failing to prosecute Medicaid providers who made contributions to their campaigns and engaged in fraudulent conduct.

Closely drawn limitations. The restriction on contributions must not unnecessarily abridge associational freedoms. Considering statistics that reveal only .003 percent of the state’s Medicaid providers committed Medicaid fraud in a one-year period, the restriction preventing of all such providers from making contributions is more broad than required.

Standing to bring suit. The providers had standing to bring the suit despite the fact that the election year in which they wished to make campaign contributions had ended. Since they were unable to litigate the issue prior to that election, and they have indicated their desires to make such contributions in the future, the court had jurisdiction to hear the case.

This week, the FDA advised against expanding the use of drug Xarelto for acute coronary syndrome. A study found that, in 2010, over half of all individual health insurance policies failed to meet exchange requirements. Also this week:

Ohio hospitals are losing money as the number of Medicaid patients increases and the number of privately insured decreases.

In merely four years, Ohio hospitals have seen Medicaid payments through state-funded managed care programs triple, rising from $835 million in 2007 to $2.36 billion in 2011. Meanwhile, during the same period, the number of patients covered by private insurance plans has dropped. Hospitals are concerned about these numbers, given the fact that Ohio budget cuts have resulted in the hospitals receiving about 82 cents for every dollar spent on the care of patients covered by Medicaid.

Before the cuts, the hospitals were receiving 95 cents per dollar spent on Medicaid patients, and the deficit was covered by charging inflated prices to private insurers, also known as “cost shifting”. Those inflated charges also covered the cost of care for uninsured persons who were provided with emergency room care, as required by the federal Emergency Medical Treatment and Active Labor Act (EMTALA). This is a particular problem for Ohio hospitals, which receive 34 percent more emergency room visits than the national average. The greater the losses hospitals incur from treating Medicaid and uninsured patients, the more hospitals feel pressured to increase charges to privately insured patients and pass on the burden of the loss.

As the number of privately insured patients declines and the number of Medicaid and uninsured patients increases, hospitals are becoming increasingly worried about how to cope with the losses they incur. According to the Columbus Dispatch, “even a 1 percent shift in revenue from more profitable private-pay sources to Medicaid can have significant consequences for a hospital or health system.” The article gives an example of one Ohio hospital that lost more than $50 million per year between 2007 – 2011 due to a 3 percent shift from private payers to Medicaid reimbursement.

Especially at risk are Ohio children’s hospitals, where more than half of the patients treated are covered by the Medicaid program. A report issued by the Ohio Children’s Hospital Association concludes that significant increases in public sector funding for Medicaid reimbursement are necessary for hospitals to maintain the quality and cost of care that is currently being provided.

Increasing the hospitals’ anxiety are the state health care insurance exchanges, which are required to go into effect in 2014 under the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148). While the implementation of the exchanges will sharply decrease the number of uninsured persons, it is expected that many of the newly insured patients will be covered by the expanded Medicaid program. As more patients are provided with care below cost, many experts expect that private insurance coverage will continue to decline as employers cease to provide health care benefits to employees.

A possible result? The cost of private insurance continuing to rise, causing even more employers to drop coverage for employees, forcing more of them on the public Medicaid rolls.